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ct <br /> STATE OF CiAL.IFORNI WATER RESOURCES CONTRI1 BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PR6dRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK" N K COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> _ IC <br /> MARK ONLY ❑ 1 NEW PERMIT �3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES 0 NO ji. <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: p( 6 <br /> 11. TANK 5ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. F-� 1 UNLEADED LEADED,. 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL �RODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> �95 UNKNOWN E]2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 11 5 HAZARDOUS 80 EMPTY <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEMffi-f'SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> aq-t-SEELARON F-1 2 STAINLESS STEEL F-�3 RBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 8.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE O 7 UMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERUIL <br /> 9 BRONZE 10 GALVANIZED STEEL NKNOWN 99 OTHER <br /> 1 RUBBER LINED F-�2 ALKYD LINING F-�3 EPDXY UNING 4 PHENOUC UNING <br /> C. INTERIOR <br /> LINING ❑5 GLASS LINING 6 UNLINEDUNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:]NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYPHLENE WRAP 2 TAR OR ASPHALT F 3 AWL WRAP F 4 FIBERGLASS REINFORCED PLASTIC <br /> oll <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A a 95 UNKNOWN A U 99 OTHER <br /> I. <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTINGP 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH <br /> GALLONS <br /> SUBSTANCE REMAINING IN INERT MATERIAL? Ej YES [-]NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE . <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY# FACILITY ID# TANK ID--T�4 <br /> N <br /> � I I I -j F7 16W] / I3I oQO <br /> CURRENT LOCAL AGENCYFACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> S R <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> t <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: <br /> aiiii <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPAWK BY A FACILITY/SITE APPLICATION, FORM'A',UNLESSIMIRRENT FORMA HAS BEEN FILED <br /> DATA PROCESSING COPY <br />